Ramblings of an Emergency Physician in Texas

Bedside manner

I just had a personal experience with a doctor with a relative lack of bedside manner, and it was illuminating.

I took my largest organ (skin) to my dermatologist yesterday, as I had a few new problem areas to be looked at. (This was after about a six week wait for this appointment). My skin doesn’t like sun, or apparently bright lights. I digress.

I’ll tell you now they don’t know I’m a doctor there, and that’s okay with me. I haven’t hidden it, but I don’t announce it to anyone, either. (The only people who routinely find out I’m a doc are my barbers, who are a decidedly chatty bunch).

I waited long enough to read a couple of magazine articles, and in came the Dermatologist (Derm) and his assistant, and a PA student. No-one introduced themselves except Derm, and his intro was a grunted “Huhmm. What’s the problem?” I appreciate directness, so I outlined my little problems, and after a thorough exam, during which very very little was asked or answered, he said “I think we need to take those off”. I wholeheartedly agreed.

After 2 more magazine articles Derm reappears with the entourage, asked me to lie down, and without a word starts to numb one of the spots, the one on my right eyelid. He does it with skill (I’d know) but without warning, and all three (two others, all on the face) were taken care of efficiently, and without warning, narrative, etc. It didn’t hurt more than a 1/10 at worst, and the procedure was a success (I hope).

However, Derm’s lack of any appreciable bedside manner has me reevaluating one of my longest-held beliefs, that people don’t really care if their doctor has a great bedside manner, but only really want a doctor who is very competent and does the job right.

And, painfully, I have to look hard at myself. I am, occasionally, a touch cranky. I try very very hard to not be cranky toward my patients, but I’m not in such denial to say I never act cranky with a patient.

Comments

Interesting. You know, I have never encountered that somewhat stereotypical attitude among military (or at least Air Force) physicians (and PA, NP, etc). Almost without fail, they are pleasant and introduce themselves.

When you are under someone else’s care, you are vulnerable. No matter what your intellectual side says, you are going to be strongly influenced by your gut intuition. Does this person care for me? Is he trustworthy and kind?

‘Kind’ is an old word, related to the word ‘kin’. Treating someone kindly means treating them like kin. This doc did not treat you the way you’d treat members of your kind, and you noticed it right away – your gut perceived that as a critical sign, an indication that you might not be safe in his care.

I’ll bet that once you reveal yourself as a doctor, you get acknowledged as kin and the illusion vanishes.

Jeezz o’ peez! You’re a physician, you knew what was coming. C’mon, you knew that he was going to have to anethestize the area locally. You know the routine. What kind of warning do you need? And you even said it yourself that “it didn’t hurt” much. Maybe he wasn’t as “chatty” as the barbers but the man did everything right didn’t he? Sounds to me like you’re one of those “needy” patients who needs to have their hands held and ego stroked. There, there…

Regardless of what they say, people care about bedside manner more than they probably should. Malcolm Gladwell in his recent book Blink details the phenomena of patients not wanting to sue doctors who “are nice to them” despite making an error in their treatment. Furthermore, patients who have sued their doctors are not willing to include other physicians in the suit who may be culpable but displayed genuine concern and care about their wellbeing during the consultation.

Bedside manner only counts for me on the first instance of disagreeable interaction. After I recover my composure, I always weigh the good versus the bad, and I usually come up with the same verdict:

I don’t pay my healthcare providers to be sweetie-pies. I pay them to be competent, to get the job done.

The sweetie-pies are a special bonus, a grace unlooked-for, if you will. I can think of two, maybe three, rather disagreeable providers that regularly treat me. I respect their skills enough to return to them. And I treat with them on that level only.

And I don’t mind acknowledging that the sweetie-pies sometimes seem to know just when to be disagreeable. I respect that, too.

I don’t think providing a little “warning” or “narrative” is good bedside manner – it’s keeping the patient informed as to what’s going on with the procedure, and to me that’s not optional. If you’ve been to this doc before for the same procedure and you know the drill, no big deal, but (as far as you know) he didn’t know you’re also a physician, so he should have assumed you had no more than “man on the street” knowledge and provided appropriate commentary. I don’t expect a lot of hand-holding from my medical providers, but I damn sure expect to be told what’s going on, good, bad, or otherwise. If someone’s building me a house, I expect to be in the loop. Working on my body? The expectation is doubled (at least!).

David, I met a few mil docs who were jerks, but they were the true exception.

For Soar and Bob: yes, I suppose it didn’t meet my expectations, specifically “How I’d have done it”. As I routinely do painful procedures on others, I have a little routine where I talk the patient all the way through and keep them informed of the progress.

Expectations. I made the very common error of just assuming Derm would do what I do. Wrong.

IMHO, the derm’s MO is behavior on the sour side of poor. He was rude and arrogant, and showed no more respect for his patient than a turnip. I agree with Bob; if someone is working on my body, I expect to be in the loop, and I do not think that the comment “Those have to come off” is anything more than a vocalization of current observations – it contains no information whatsoever about future plans. “Competent” includes sharing information in a timely fashion.

I’m a doc, too. I recently sat in the hospital room of my dad, and witnessed the following: a doc came in with a couple of medical students. The doc did not introduce himself or the students, but did say he was going to listen to dad’s lungs. My mom was sitting next to the bed, very worried (this was the beginning of the hospitalization during which dad died.) The attending listened to dad’s chest, and then talked to the students, and briefly to my dad, never acknowledging my mom at all, and exited in a self-satisfied flourish. Virtually no information was exchanged, and there was no attempt to communicate. It didn’t seem that the attending felt communication was a priority at all. It embarassed me, as a fellow physician. After they left, I could see them standing in a clot outside the room; I excused myself and went out and, addressing only the students but in full view of the attending, I said “I’ve been a physician for nearly 30 years. You are just starting, so you may not have recognized that you just witnessed the worst example of patient care I’ve ever seen, and I hope you don’t take it as an example of what should be done.” And I enumerated the transgressions. I can’t say for sure, but I think it was the best lesson the students got that day, and one the attending should have gotten years ago. There’s no excuse for doctors treating patients as if they are on a lower plane than themselves. We are, after all, just people who went to a different school.

As a RN who makes rounds frequently with surgeons or consulting physicians, I must say that the vast majority of MD’s are lacking in their bedside manner skills. I know most MD’s who must make rounds daily are probably tired of the same ole grind, same ole complaints or whatever. But you would not believe the number of times I have had MD’s never introduce themselves, never recognize anyone else in the room (even the nurse) and never even lay a hand/steth on the patient. Once they leave it’s up to the RN to answer the patients questions (since the MD has come and gone before they could say a word), make the patient feel comfortable and accepted, and take care of the MD’s orders. And worse yet, from what I have read here in the comments and in the post, their are students watching and learning that this is an exceptable practice. I know not all Docs are this way, but most are.

OK, so it seems you have a taste of your own medicine. Why make the derm guy out to be any worse than yourself? How do you know his day with you wasn’t as bad as one of the days you see yourself as having been less than your cheerful self? Being hurried, distracted, tugged-on by one patient after another who want more time than allotted and don’t want to wait another day for an appointment but seem annoyed when they have a late doctor who sees dozens of patients with these same expectations every day. Certainly a private mental note would have been worthwhile, but here it is on your blog.

And Sid Schwab, all I can say is that I hope you enjoy your retirement. If you had any class at all, you would have asked to speak with the offending attending privately instead of blowing off like a pompous jerk in front of everyone there. You were playing the perfect part of the intrusive and overbearing medically-trained family member whose behavior does more to poison the relationship between doctor and patient than anything else. Your colleagues and other doctors aren’t perfect, but I doubt you were either. And I doubt you made the impression you think you made, probably more to the opposite. Your mom became the lady with the jerk for a son. Sorry if that hurts.

I don’t get your objection to my outlining poor bedside manner and internalizing the lesson therein. Frankly, if I didn’t blog about things I see / feel this would be a blog full of links with “Indeed” attached.

And I find it amusing you call out Dr. Schwab in the comments of this blog when, given your objection to his approach and a recommendation it be handled privately, you didn’t just email him directly.

Great Post. I linked to it and wrote my own post about this from a nurses perspective @intelinurse2b.blogspot.com
My point? Nurses are held to such a higher standard when it comes to bedside manner. Im not bitter…lol. But its a fact. Awesome post-thanks for the realism-its always refreshing when physicians share their personal side as a patient.

Bedside manner comment certainly are a hot button for docs and patients. I’m just a patient, though one who has been through three surgeries in the last 10 months, and face two more. I have learned that if a doc doesn’t have a decent bedside manner, it is time to find a new doc. Period. Great hands and a poor manner do not promote healing. So I’ve learned to select docs who will listen, talk, react, and treat me as a partner in the healing process. I get better quicker because we can both work on the case. Docs know a lot, but the patient is still the expert on his own body.

I had a derm who was very similar in style to the one you mentioned. Given that I have to get fully disrobed in front of some derm every 6 months, his brusque “undress-sit-down-and-shut-up” manner at ALL. Huffing at my questions about my BCC and SCC was the final straw. I put up with the attacking my nose with the scalpel fairly well in my estimation, but really, displaying annoyance at my questions about prevention was ridiculous.

Which is why I have happily been seeing a different doctor for 2 yrs now. Not longer face time, but the time spent is full of constant communication. This is why I am doing this, this is why I am doing this, and very responsive to my questions. Derm #1 doesn’t have to be annoyed by my presence anymore, and I don’t need to feel violated every time I need a biopsy.

Several months ago, I had a pre-employment physical done by a retired internist, who had been on the staff at a large teaching hospital. I couldn’t believe it – he talked to me the entire time he was examining me. I don’t mean chatting about the weather. I mean asking me a lot of questions about my health. And he did it in a professional way, listening to what I said. And he actually touched me – checking out my heart, lungs, arms, legs, hands, etc. I haven’t had such a thorough physical since I was a kid at the pediatrician’s. Are doctors like this no more to be found?

And it didn’t take this internist long to do his exam, maybe 12 minutes. But I definitely felt like the 12 minutes were well spent, both for him and for me.

My current family practice doctor, if she wants to examine me, she inspects the results from the last bloodwork I had. And that’s about it, unless I bring a subject up.

I don’t particularly mind if a specialist is on the brusque side, as long as they seem attentive and will let me ask a couple of questions. But there are definitely some who won’t even allow this much interaction to take place. It’s as if they want to deal with your health problem, but not with you the human.

I was google searching some humor for an ER doc out in Iraq (old friend), and I ran across your website. I am a (former enlisted reserve)Marine and now an ICU nurse, and I found some of your humor *priceless*. I haven’t had that good of a laugh in so long. (Asnear to stress incontinence as one chooses to get at 33.) Keep up the good work!

P.S. The crankiness is only out of the frustrating part of working with the carp in the gene pool. We get the polysubstance partiers and gang-bangers with more gang than bang here by Detroit airport. **It happens. ;)